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{ <br />ENVIROAENTAL HEALTH D A <br />RTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone #C <br />-� <br />G <br />Facility Name' �` �� -tel # . <br />Phone # _I <br />Address 1 <br />TCross <br />Street <br />Y <br />Owner/Operator t <br />Phone <br />9121-0992 <br />C <br />0 <br />Contractor NameF-1 ikLaPhone <br />.#FW <br /># <br />N <br />T <br />Contractor Address <br />CA Lic # Class <br />RInsurer <br />A <br />a <br />1 <br />Work Comp # _r1� <br />`�J <br />c <br />;�. .•` <br />1 i { i+ i kRi� <br />it {+,_M <br />M«.1 ki + <br />T <br />ICC Technician's Name <br />Expiration Date <br />oJCC <br />R <br />Installer's Name <br />Expiration Date <br />. i , . , <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved pproved with conditions ❑ Disapproved <br />A <br />e ttaent With Conditions) <br />N <br />Plan Reviewers Nam Date <br />APPLICANT MUST PERFORM ALL W RK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature Titlef 1Ci�i�� �_ Date CCsYI 11�7{l [ l� l <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. �q�}�t <br />NAME Et I�E -ID i L�C1T&i� <br />C?C�P.S r "Cl�imlTITLEt "�}l�(c <br />M <br />nvt�rc�oo � g <br />SIGNATURE_ \�''�, �� <br />DATE <br />EH230038 (revised 08/1/11) <br />• <br />2 <br />M' �t�•Mr.1 « <br />tti f <br />, ,«M IR Yii� <br />+.-_�.. 1il f•t <br />;�. .•` <br />1 i { i+ i kRi� <br />it {+,_M <br />M«.1 ki + <br />4+i+,{. <br />, , ; <br />•^ <br />«Mil. { •*�_�i <br />+ M { + , , ... <br />.. <br />. <br />. i , . , <br />